Failure to Develop Comprehensive Care Plans for Anticoagulant Use and Significant Weight Loss
Penalty
Summary
The facility failed to develop comprehensive care plans that addressed the specific needs of two residents. For one resident with a diagnosis of paroxysmal atrial fibrillation, a physician ordered apixaban, an anticoagulant medication, but the resident's care plan did not include any interventions or monitoring related to the use of this medication. This omission was confirmed during a medical record review and interview with a licensed nurse, who acknowledged that the care plan should have been updated when the medication was ordered. Another resident, admitted with diagnoses including malignant neoplasm of the esophagus, dysphagia, and muscle wasting, experienced a significant weight loss of 6.5% in one month, as documented in weekly weight records. Despite this notable change, there was no evidence in the resident's care plan that addressed the weight loss. This finding was verified during a review of the medical record with the assistant director of nursing.